Helping a Suicide When the End Isn’t Near

Debaters

Mark A.R. Kleiman is a professor of public policy at New York University's Marron Institute of Urban Management and the author of "When Brute Force Fails: How to Have Less Crime and Less Punishment."

No One Who Clearly Wants To Die Should Be Forced To Live

Mark A. R. Kleiman 3:30 AM

Most suicide is impulsive. Most of the people who try to kill themselves are in the grip of a transient mood, often due to depression or other mental illness, or to alcohol. Preventing those deaths, and treating the underlying disorders, are clearly public-health and medical tasks.

Some people's lives are so miserable, they clearly prefer to end them. Some suffer from intractable pain. Others find their powers failing.

But there are other people whose lives are so miserable that they prefer to end them, and who felt that way last month and would still feel that way next month. Some suffer from intractable physical pain. Others find their physical and mental powers failing and hate the thought of being dependent on others for basic activities such as eating and keeping clean.

Right now, under the laws of all 50 states, those people are forbidden to end their own lives, and would be “rescued” against their will if they try. Some states have “Kevorkian laws” making it a felony to help anyone else kill himself.

Some exceptions are made, by law in three states and custom elsewhere, for people who are near death. Everyone is expected to wait patiently for the Grim Reaper. Why? What could justify requiring someone to live who seriously prefers to die?

Of course, if the laws were changed, it would be necessary to separate out determined suicides from impulsive ones, to determine whether people asking to be killed were under pressure from health-care providers or family members to end lives that had become inconvenient to others, and to identify instances where better medical treatment or social care might eliminate the desire to die. People for whom the source of suffering is profound clinical depression pose the hardest cases, because the disease makes it difficult to determine what the subject “really wants.”

But the fact that a problem is hard isn’t a good enough reason to choose an easy, simple, wrong answer. Current laws create untold amounts of avoidable suffering. It’s time to change those laws.

Society Must Discourage Suicide, Not Facilitate It

Ira Byock 3:30 AM

Should a person who is not terminally ill be allowed to commit suicide? If so, should physicians be permitted to assist in causing the person’s death? Should non-physicians?

These are critical issues. Many people’s lives are miserable with no end to their suffering in sight. We are living through unprecedented circumstances in which society is strained by widespread poverty, chronic illness and disabilities, mental illness and drug abuse. Ours is also an era in which previously outlawed or socially deplored behaviors are increasingly accepted, whether or not they are legal: same-sex marriage, marijuana use and physician-assisted suicide for terminally ill people.

Even archaeological evidence bears out the life-preserving nature of the social compact, especially for the most vulnerable.

Nevertheless, I can answer each of these questions unequivocally. Society should discourage suicide. Assisted suicide should be illegal. And if the populace insists on making assisted-suicide legal, physicians are the wrong professionals to do it.

This stance is rooted in fundamental social and ethical principles and will be criticized for seeming out of touch with contemporary realities, or worse still, heartless. Neither is true.

Principles are the I-beams of social architecture. In defining basic roles, rights, responsibilities and prohibitions, principles protect us – especially the most vulnerable among us – in times of turmoil and strife.

The life-preserving nature of the social compact is borne out by archaeological, anthropological and historical records. The medical profession was formed to protect and preserve life and to alleviate suffering. So too were nurses, policemen, firemen and more recently emergency medical technicians, search and rescue squads and Hazmat teams. Our military protects us from malevolent others, and helps save lives during natural disasters. We invest heavily in public services of sanitation and water treatment, food, air and water quality inspections to protect our lives and health.

Suicide, assisted suicide and physician-assisted suicide are distinct acts. Suicide has existed from antiquity, and has always been discouraged. Rational suicide represents the ultimate, unilateral exit from society; therefore, its illegality strikes me as meaningless. But, except in self-defense, intentionally ending another person’s life remains wrong, on principle.

Ending Incurable Suffering Must Be an Act of Compassion

Mark A. R. Kleiman 3:30 AM

Preventing death is usually desirable, and we have institutions and professions to serve that purpose. But it does not follow that preventing death is always desirable. For people who are, as Dr. Byock says, “miserable with no end to their suffering in sight” and who want to die, preventing death is merely prolonging suffering.

Physicians and family should have no role. But it should be possible to find people willing to learn to help strangers die comfortably.

It would be wonderful if laws against suicide were “meaningless.” In fact, people are prevented by force from acting on their wishes to stop living, and “rescued” when they desperately want not to be rescued. Many of the people who most desire to die are in hospitals or nursing homes, with dedicated professionals doing their best to make suicide impossible.

The laws also force suicides to be furtive, with no support from family and friends.

Most of all, the laws prevent people who need help in dying – because they are physically or psychologically incapable of carrying out the task themselves – from getting that help.

I agree that physicians and other health professionals should have no role in the process (other than providing, on request, information about a patient’s physical and mental condition and how it is likely to change over time).

Ensuring a painless death isn’t a technically hard problem, and doesn’t require an M.D.; whether it’s worthwhile for someone to go on living is not a medical question. Let’s not confuse the physician’s usual role as life-saver with a somewhat incompatible role as life-ender.

For similar reasons, family and friends should not be allowed to provide material help in dying.

And no one should be paid to help end someone else’s life; if the task is worth doing, it’s worth doing out of compassion. People learn CPR so they can help strangers stay alive; it should be possible to find a sufficient number of people willing to learn how to help strangers die comfortably.

Don’t Hasten the Slide Down the Slippery Slope

Ira Byock 3:30 AM

Preventing death is not always desirable and many people are suffering. The question is whether society should sanction hastening death.

Not long ago proponents of Oregon-style physician-assisted suicide laws assured us that the slippery slope was imaginary; extensions to non-terminally ill people and to euthanasia were impossible because of legal safeguards. Now the slope seems more real to some of them. By including people who are “physically or psychologically incapable of carrying out the task themselves," Professor Kleiman has broadened the discussion to euthanasia.

If it is purely a matter of personal liberties, what level of suffering qualifies for hastened death? In Europe we've seen chilling examples.

These are all accepted reasons for euthanasia in Holland, Belgium and Switzerland.

Some suffering people desire death because they feel trapped in intolerable circumstances. I’ve lost count of the number of frail elderly patients who told me that they would rather die than be confined to a nursing home. “Just push me down the stairs” one said. “Please shoot me before you send me there,” another remarked. I get it. Many of our nation’s nursing homes are little more than human warehouses, hardly places worthy of caring for our grandparents, parents, siblings, spouses, children and neighbors.

A desired painless death is a lot less expensive than the roughly $100,000 annual costs of unwanted nursing home care.

How about someone facing many years in prison and life-long ignominy? Would we offer the option of suicide to Bernie Madoff? Jared Fogle? This, too, would be less costly than unwanted institutionalization. This is not far-fetched. In 2014 a Belgium court granted a prisoner’s petition to be euthanized rather than serve his life sentence for murder and rape. Some hailed the decision as “the ultimate gesture of humanity.”

On this side of the looking glass, it is chilling.

Assisted Suicide Is Self-Determination, Not Euthanasia

Mark A. R. Kleiman 3:30 AM

Dr. Byock and I are definitely on different sides of the looking-glass. He finds it chilling that a person might choose to die when he would prefer that person to live. I find it chilling that anyone would presume to make that choice for another competent adult.

This isn't euthanasia, killing someone you think would be better off dead. This is helping people who think they’d be better off dead.

He sees the question as “whether society should sanction hastening death.” I see the question as whether there’s an entity called “society” that can rightfully claim more power over my life than I have. Dr. Byock asks “What level of suffering qualifies for hastened death?” I answer, “Whatever level of suffering the person actually doing the suffering finds intolerable.”

Should a congenitally deaf man who is now losing his sight be required by law to live on in dark, silent isolation? I think not. It’s not a question of whether “we” approve, whoever “we” may be. It’s a question of whether to force someone to suffer who would prefer to stop suffering.

Assisted dying is not euthanasia. Euthanasia is killing someone because you think he would be better off dead. Assisted dying is helping someone die because he thinks he’d be better off dead. It’s precisely the difference between rape and consensual sex. Allowing people to have sex doesn’t put us on the “slippery slope” to legalizing rape.

Of course there should be strong rules against applying any sort of pressure on someone to choose to end his life early. For patients with severe mental illness or cognitive disability, the question will arise whether the request for help in dying reflects the person’s genuine choice, and we will need legal procedures to make those judgments, just as we do now about other medical choices where the competence of the patient is in doubt.

But why assume, without offering any argument but what Leon Kass has called "the wisdom of repugnance," that all hard questions must be resolved in the direction of involuntarily prolonged suffering?

There’s So Much We Can Do to Alleviate Suffering

Ira Byock 3:30 AM

Human beings are social animals. We require human connections to be healthy. Rational suicide can be an escape, but that does not make it less tragic, nor reliably less painful for the deceaseds' loved ones. As I heard the psychiatrist Ned Cassem observe several times, suicide is often the act of leaving one’s skeleton in someone else’s closet.

We can transform nursing homes, expand access to effective pain relief and to treatments of depression that are shown to work.

A healthy human community does everything in its power to prevent and alleviate suffering among its members. If you share that commitment, there is so much we could achieve.

We could transform nursing homes, so that fewer people would want to die rather than be confined to hellholes. We could push legislation to annually rescind the licenses of nursing homes that rank lowest on safety and resident quality of life. Those licenses should go to Green House or Beatitudes-style homes that actually nurture frail people.

Policy changes could enable millions of Americans suffering with chronic pain to receive treatments that work. Clinical studies repeatedly show that combining analgesic medications with physical and occupational therapies, resiliency training, exercise, meditation and career counseling can make life worth living for most chronic pain sufferers. It is cruel irony that funding for these evidence-based approaches has disappeared in favor of ineffective surgeries, injection clinics and drugs.

Depression is surely the cause of most rational suicides. Here too, effective treatments exist, which don’t fit the current medical-industrial business model. Mindfulness meditation can halve the recurrence rate of serious depression with no side effects. It’s just not covered by insurance. Psychotherapy with medically administered psilocybin and similar so-called psychedelic drugs has been strikingly effective in people with persistent depression. One or two sessions often result in many months of improvement. Many no longer need daily antidepressants. Is it any wonder that the pharmaceutical companies are not pushing for expanded research or the relaxation of legal restrictions on these medications?

Even while we vigorously debate, we could work together to diminish the reasons people desire death.

Introduction

André da Loba

Several states have passed laws allowing terminally ill people to commit suicide with help from a physician, and more states are considering it. Some nations, though, have gone further, by permitting such assistance to people with serious, nonfatal, health problems, even severe depression. Is that a dangerous step on a slippery slope toward euthanasia, or an appropriate way to help people who suffer unbearably? Should some people who are not dying be permitted assistance in killing themselves?